Forget drugs or surgery. Prolotherapy is an effective and non-invasive way to alleviate chronic joint pain in your companion.
Stiffness, lameness, pain…they’re common joint problems in many older animals. Unfortunately, chronic pain from tendon and ligament issues and injuries is one of the most difficult disorders for a veterinarian to cure.
Before any sign of arthritis shows up on an x-ray, the animal is often suffering from an intermittent lameness that worsens after exercise. Referred to as a “soft-tissue injury”, most veterinarians will treat it with non-steroidal antiinflammatories and rest. But tendons and ligaments generally have a poor blood supply, and incomplete healing is common after injury. That means these normally strong bands of fibrous or connective tissue become stretched out, weak and a source of pain.
The points subjected to the most mechanical stress in the body are where the tendons and ligaments attach to the bones. These points are also the areas of highest weakness in the ligaments. This is what makes them so prone to injury. In addition, the highest concentration of pain sensors inside the body is found in the periosteum (the thin connective tissue covering the bone) and the ligaments. On a scale of pain sensitivity, where we look at which part of the body hurts most when injured, the periosteum ranks first, followed by ligaments, tendons, fascia (the connective tissue that surrounds muscle) and finally muscle. Cartilage contains no sensory nerve endings. When cartilage is damaged, tendons and ligaments are usually damaged as well, and that’s what hurts.
Ligaments and tendons are made of taut bands of collagen, a fibrous material and the building block of connective tissue. The tough gristle in your steak is made of connective tissue. In tendons and ligaments, the collagen fibers are oriented like the strands of a rope. Damage in these structures leads to increasing looseness (laxity) in the joints they support. The abnormal mechanical strain caused by this laxity leads to joint degeneration and osteoarthritis.
When there is a complete tendon or ligament tear or rupture, such as commonly occurs in the anterior cruciate ligament of the stifle (knee), or in the gastrocnemius (Achilles) tendon of the hock (ankle), surgery is the best option for stabilizing the joint. But what about partial tears? Currently, most veterinarians recommend surgery for those as well, since they are weak areas and prone to fully rupture in the future. But many people would rather not have a surgical procedure performed on their animal if there is a viable alternative.
Good news! Another mode of therapy can strengthen those weak structures. It’s called prolotherapy. The prefix “prolo” means “offspring” in Latin. Prolotherapy is also called “proliferation therapy” or “regenerative injection therapy” (RIT).
It was first developed in Germany in the late 1800s and was refined in North America by Drs. Hemwall and Hackett in the 1950s. Dr. Hemwall published a large survey (involving 1,871 patients) in which 75.5% of participants stated that prolotherapy cured them. Nearly all the patients (99.8%) reported some improvement. Only 0.2% reported no improvement. Veterinarians started performing prolotherapy in the 1970s by studying with physicians trained in the procedure, and now specific veterinary courses in prolotherapy are offered. Prolotherapy involves the injection of sterile nutrient solutions or platelet-rich plasma (PRP) directly into weakened connective tissues such as joints, tendons and ligaments – especially at the point of attachment to the bone, the area that is weakest and produces the most pain. This injection promotes increased collagen formation. This is mediated by stimulating the growth of local stem cells. The injections trigger the release of growth factors stimulate stem cells to proliferate and differentiate into the cells necessary for repairing the injury or degenerative condition.
The growth factors include Insulin-like Growth Factors I-IV, Transforming Growth Factor Beta, Epidermal Growth Factor, Basic Fibroblast Growth Factor, Platelet Derived Growth Factor and many others. These are released during prolotherapy treatments and appear to be the main basis for repair. It has been shown that elevating the concentration of glucose (sugar) by 0.5% in the fluid surrounding the fibroblasts induces the DNA machinery to release numerous growth factors such as those mentioned above.
PRP is prepared by drawing a small quantity of blood from the patient, which is then placed in a special processing centrifuge that separates platelets, white blood cells (WBC) and serum from red blood cells. The platelets and WBCs are then concentrated and collected into a sterile syringe. Some of the blood is used to create an “activator” of the PRP. The concentrated mixture of platelets and WBCs are then injected into the injured site. The concentrated platelets release and trigger local cells in the injured tissue to release the growth factors that stimulate healing.
Different prolotherapy “cocktails” are used by different practitioners, and can include dextrose, vitamins and homeopathic solutions. A small quantity of local anesthetic is included to reduce the immediate discomfort of the injection, and prevent “wind-up” pain, which occurs when nerve cells are stimulated and continue signalling pain even when the source of injury is gone.
The healing effect is a graded, controlled reaction producing repair of weak and damaged connective tissue. When properly applied, prolotherapy does not induce scar formation. The bonds in the connective tissue are stronger and healthier, and the tissue is thicker than before treatment. With each treatment, tissues continue to strengthen until the healing is complete and the pain resolved. Joint laxity decreases due to a strengthening and tightening of the treated tendons and ligaments. This reduces or eliminates pain from muscle spasms and also reduces the need for the body to produce excess bony tissue to assist stabilization, as occurs in osteoarthritis.
Since the injections need to be placed with great accuracy, and may cause temporary discomfort, most dogs and cats will require a sedative for the procedure, and some may need a short general anaesthetic. The typical hospital stay is half a day. The injections can be placed into multiple locations at one session, and usually a series of three to five sessions, two to four weeks apart, is required.
Any injection carries with it a small risk of infection, but this is rare in prolotherapy and minimized by the use of strict sterile techniques. All prolotherapy solutions are sterile materials labelled for injection. PRP is produced from your animal’s own blood, so there is no concern about rejection or disease transmission. Recent research even suggests that PRP may have antibacterial properties.
Non-steroidal anti-inflammatory medications such as Rimadyl, Deramaxx, Metacam and aspirin should not be used during prolotherapy treatments because they stop the release of the growth factors essential to the therapy’s effectiveness. It is not usually necessary to use pain medication for more than a few days after the treatment. Ice and rest provide comfort in the first few days, then heat, stretching and passive range of motion exercises are added. Rehabilitation exercises to help strengthen weakened muscles are also often used to support the healing process.
Veterinarians trained in prolotherapy can be found around the world. Many are listed on the American Holistic Veterinarians Association’s website at ahvma.org.